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编者按:绝大多数抗癌药物剂量都是从最大耐受剂量开始,如果患者难以耐受,那么逐步减量,直至患者耐受或者停药。从大剂量开始的好处是迅速杀死癌细胞,坏处是患者难以坚持治疗,尤其对于术后短期复发风险较低、长期复发风险较高、需要长期治疗的早期癌症患者。
激素受体阳性HER2阴性早期乳腺癌确诊后数十年内都有远处复发风险,某些临床和病理特征预示复发风险较高,包括腋窝淋巴结转移、肿瘤较大和肿瘤分级较高。对于高风险患者,包括高风险淋巴结阳性患者,大约30%可能出现病变复发,大多为远处转移。对于复发风险较高患者,标准术后内分泌治疗添加入CDK4/6抑制剂(阿贝西利或瑞波西利)可显著改善无浸润病变生存。monarchE研究已经证实,对于激素受体阳性HER2阴性高风险淋巴结阳性早期乳腺癌患者,标准术后内分泌治疗加用2年阿贝西利(每天2次口服150毫克)与单用内分泌治疗相比,可显著改善中位无浸润病变生存、远处无复发生存甚至总生存。不过,阿贝西利可能引起副作用,使治疗复杂化。不良事件(腹泻、中性粒细胞减少或疲劳最常见)分别导致61.7%和43.4%的monarchE研究参与者暂停或减少阿贝西利剂量。2或3级不良事件主要发生于治疗的前12周,腹泻发生时间中位8天。此外,18.5%的参与者由于不良事件而提前停用阿贝西利,治疗第1个月的停药率最高。因此,确定降低毒性和提高术后阿贝西利治疗依从性的策略至关重要,尤其开始治疗的最初几周。既往研究表明,早期剂量递增方案可能降低口服抗癌治疗早期毒性。对于HER2阳性早期乳腺癌患者,剂量递增策略成功减少术后治疗有临床意义的不良事件,例如ExteNET研究奈拉替尼组患者3级腹泻发生率达40%,由于腹泻停止治疗达17%,其中3级腹泻达7.5%,多队列CONTROL研究奈拉替尼剂量递增方案将3级腹泻发生率降至15%,仅3%的参与者由于腹泻停用奈拉替尼。此外,DESIREE研究依维莫司剂量递增策略降低有临床意义的不良事件发生率,并提高晚期乳腺癌患者的治疗依从性。
2025年10月17日,欧洲肿瘤内科学会官方期刊《肿瘤学年鉴》在线发表美国哈佛大学医学院德纳法伯癌症研究院、德纳法伯布莱根癌症中心、新英格兰癌症医院、贝斯以色列女执事医疗中心、贝内特癌症中心、波士顿医疗中心、北极光医疗中心、意大利米兰大学欧洲肿瘤研究院的TRADE研究报告,首次前瞻尝试淋巴结阳性早期激素受体阳性HER2阴性乳腺癌患者术后阿贝西利短期剂量递增策略能否改善耐受性、降低停药率并提高治疗初期剂量达标率。
TRADE (NCT06001762): Dose Escalation Tolerability of Abemaciclib in HR+ HER2- Early Stage Breast Cancer
Official Title: The TRADE Study: A Phase 2 Trial to Assess the ToleRability of Abemaciclib Dose Escalation in Patients With Early-Stage HR-positive and HER2-negative Breast Cancer
该多中心单组二期临床研究于2023年10月至2024年9月在12个研究中心入组淋巴结阳性激素受体阳性HER2阴性乳腺癌且术后适合阿贝西利联合内分泌治疗患者90例,阿贝西利开始剂量为每天2次50毫克连续2周,随后每天2次100毫克连续2周,最后每天2次150毫克。剂量递增前提为未发生3至4级或持续2级毒性反应。主要终点为12周时阿贝西利由于任何原因停药或无法达到或维持目标剂量的综合不良事件发生率。
结果,主要终点中位随访32.1周,其中1例患者完成术后阿贝西利治疗12周前复发,其余89例患者12周时综合不良事件发生率仅29.2%(90%置信区间:21.3%~38.2%)显著低于monarchE研究历史数值40%(P=0.023)。其中仅6例(6.7%)患者提前停药、8例(9.0%)患者无法达到150毫克、12例(13.5%)患者从150毫克减量。大多数(70.8%)患者达到并坚持每天2次口服150毫克。
因此,该研究结果表明,术后阿贝西利剂量递增策略可使超过70%的患者达到并坚持标准剂量,早期停药率低于7%,12周时治疗坚持率高于93%。在开始术后阿贝西利治疗时,可以考虑采用此剂量递增策略。
Ann Oncol. 2025 Oct 17. IF: 65.4
TRADE: A phase II trial to assess the tolerability of abemaciclib dose escalation in early-stage HR+/HER2- breast cancer.
Mayer EL, Trapani D, Kim SE, Faggen M, Sinclair N, Sanz-Altamira P, Battelli C, Berwick S, Lo S, Acevedo J, Sinclair S, Malcolm A, Varella L, Sammons S, Schumer S, Poorvu PD, Wallace E, Pasternak E, Tayob N, Tolaney SM.
Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Dana-Farber Brigham Cancer Center - Foxborough and Milford, MA, USA; New England Cancer Specialists, Westbrook, ME, USA; Beth Israel Deaconess Medical Center, Boston, MA, USA; Bennett Cancer Center, Stamford Health, Stamford, CT, USA; Boston Medical Center, Boston, MA, USA; Northern Light Health, Brewer, ME, USA; European Institute of Oncology, IRCCS, Milan, Italy; University of Milan, Milan, Italy.
HIGHLIGHTS
Adjuvant abemaciclib reduces risk of HR+ HER2- breast cancer recurrence; however, therapy can be complicated by toxicity.
The TRADE study asks if abemaciclib dose escalation helps to reach target dose and reduce discontinuations at 12 weeks.
Results show dose escalation significantly reduced the composite adverse event rate compared to historic control (p=0.023).
With dose escalation, 70% of patients were able to reach target dose and almost 95% avoided drug discontinuation.
Adjuvant abemaciclib dose escalation can be considered as a clinical strategy when initiating patients on this agent.
PURPOSE: Adjuvant abemaciclib with endocrine therapy (ET) improves clinical outcomes in patients with high-risk node-positive early-stage hormone receptor-positive/HER2-negative (HR+/HER2-) breast cancer, based on the monarchE trial. Patients may experience tolerability issues at the standard abemaciclib dose (150 mg twice daily [BID]), potentially leading to early treatment discontinuation, particularly within the initial weeks of therapy. TRADE is a prospective, single-arm, phase 2 study evaluating whether dose escalation of adjuvant abemaciclib improves drug tolerability.
PATIENTS AND METHODS: Eligible patients had node-positive HR+/HER2- breast cancer and were candidates for adjuvant abemaciclib with ET. Participants initiated abemaciclib at 50 mg BID for two weeks, then escalated to 100 mg BID for two weeks, then escalated to the final dose level (150 mg BID). Dose escalation required the absence of ongoing grade 3-4 or persistent grade 2 toxicity. The primary endpoint, measured at 12 weeks, was a composite rate of abemaciclib discontinuation for any reason or inability to reach or maintain the target dose.
RESULTS: In 89 evaluable patients, the initial dose escalation strategy significantly reduced the composite rate at 12 weeks versus a historical value of 40% from monarchE. In total, 26/89 participants (29.2%; 90% CI [21.3% - 38.2%]; p=0.023) met the endpoint: 6 (6.7%) for early discontinuation, 8 (9.0%) for inability to reach 150 mg, and 12 (13.5%) for dose reduction from 150 mg. The majority (70.8%) reached and maintained 150 mg BID dosing.
CONCLUSION: Use of an adjuvant abemaciclib dose escalation strategy allowed more patients to reach and maintain target dosing at 12 weeks than observed in monarchE. Early discontinuation was infrequent, and 93.3% were continuing therapy at 12 weeks. This dosing strategy could be considered when initiating adjuvant abemaciclib.
KEYWORDS: abemaciclib, HR-positive, HER2-negative, breast cancer, TRADE, dose escalation
Clinical trial registration: NCT06001762, clinicaltrials.gov
PMID: 41110695
DOI: 10.1016/j.annonc.2025.09.141
(来源:SIBCS)
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